Would you like to be matched with a counselor who specializes in LGBT issues?

No

Yes

What are your pronouns?

She/her

He/him

They/them

Other

What is your relationship status?

Single

In a relationship

Married

Divorced

Widowed

Other

Do you consider yourself to be religious?

No

Yes

Which religion do you identify with?

Christianity

Judaism

Islam

Other

Would you like to be matched with a counselor who provides Christian-based counseling?

No

Yes

Do you consider yourself to be spiritual?

No

Yes

Have you ever been in counseling or therapy before?

No

Yes

Do you feel that your mental health is being impacted by the coronavirus outbreak?

Yes

No

Maybe

How would you rate your current physical health?

Good

Fair

Poor

How would you rate your current eating habits?

Good

Fair

Poor

Are you currently experiencing overwhelming sadness, grief, or depression?

No

Yes

Over the past 2 weeks, how often have you been bothered by any of the following problems:Little interest or pleasure in doing things.

Not at all

Several days

More than half the days

Nearly every day

Over the past 2 weeks, how often have you been bothered by any of the following problems:Moving or speaking so slowly that other people could have noticed? Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual.

Not at all

Several days

More than half the days

Nearly every day

Over the past 2 weeks, how often have you been bothered by any of the following problems:Feeling down, depressed or hopeless.

Not at all

Several days

More than half the days

Nearly every day

Over the past 2 weeks, how often have you been bothered by any of the following problems:Trouble falling asleep, staying asleep, or sleeping too much.

Not at all

Several days

More than half the days

Nearly every day

Over the past 2 weeks, how often have you been bothered by any of the following problems:Feeling tired or having little energy.

Not at all

Several days

More than half the days

Nearly every day

Over the past 2 weeks, how often have you been bothered by any of the following problems:Poor appetite or overeating.

Not at all

Several days

More than half the days

Nearly every day

Over the past 2 weeks, how often have you been bothered by any of the following problems:Feeling bad about yourself - or that you are a failure or have let yourself or your family down.

Not at all

Several days

More than half the days

Nearly every day

Over the past 2 weeks, how often have you been bothered by any of the following problems:Trouble concentrating on things, such as reading the newspaper or watching television.

Not at all

Several days

More than half the days

Nearly every day

Over the past 2 weeks, how often have you been bothered by any of the following problems:Thoughts that you would be better off dead or of hurting yourself in some way.

Not at all

Several days

More than half the days

Nearly every day

Over the past 2 weeks, how often have you been bothered by any of the following problems:How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

Not difficult at all

Somewhat difficult

Very difficult

Extremely difficult

Are you currently employed?

No

Yes

Do you have any problems or worries about intimacy?

No

Yes

How often do you drink alcohol?

Never

Infrequently

Monthly

Weekly

Daily

When was the last time you had a plan for suicide?

Never

Over a year ago

Over 3 months ago

Over a month ago

Over a week ago

This week

Are you currently experiencing anxiety, panic attacks or have any phobias?

No

Yes

Are you currently taking any medication?

No

Yes

Are you currently experiencing any chronic pain?

No

Yes

How would you rate your current financial status?

Good

Fair

Poor

How would you rate your current sleeping habits?

Good

Fair

Poor

How comfortable are you with your identity?

Not at all

A little comfortable

Somewhat comfortable

Very comfortable

How much of your LGBT+ identity is contributing to your mental health concerns?

Not at all

Contributing a little bit

Somewhat contributing

Contributing a lot

Solely contributing

Do you prefer to be matched with a counselor who is part of the LGBT community themself?

Yes

No

No preference

If you identify as a Christian, which denomination best describes you?

Protestant

Catholic

Orthodox

Anglican

Presbyterian

Baptist

Lutheran

Methodist

Other

Non-denominational

Not sure

Not a Christian

In order to give your counselor the right expectations, please answer a few questions about your spiritual background. How long has your faith been important to you?